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L./ _--Iu n�o(1 a <br /> ONSITE WASTP-NV$ ATER TREATMENT SYSTT [PERMIT& <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEI. ,i MENT 304 E WEBER Av; _ FL-STOCKTON CA 95202 - (209)468-3420 <br /> .NON-REFUNDABLE PERMIT CALL(209y)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS (oq <br /> rte' 7 L. CITYIZIP L(�/`Y nH�, <br /> n <br /> 'CROSS STREET tJ �r s APN C) "- PARCEL SIZE tv <br /> b <br /> OWNERNAME i GK PHONE <br /> I <br /> OWNER ADDRESS 1.j klyq'5 h/,4 CITY/STATE/ZIP ic]ai? cyf- <br /> 4 CONTRACTOR �'-e G ft PHONE <br /> CONTRACTOR ADDRESS of" Yr)G ac- �OS _ CITYISTATE/ZIP IId/1 e4 t'-L V1- e L.+ L J 2 <br /> •-LICENSE ❑C42 ❑C-36 OTHER• NUMBER g. l EXPIRATION DATE d <br /> ATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X- Y <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ElREPAIR/ADDITION 13 ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> i 1 NUMBER OF LIVING UNITS: J NUMBER OF BEDROOMS: ` NUMBER OF EMPLOYEES: <br /> /� ^� <br /> SEPTIC TANK TYPE/MFG I"' '�-" L� __ CAPACITY ' �} T5 gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> $ f <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL O + ft FOUNDATION ft PROPERTY LINE G 6() ft <br /> 0 LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> t <br /> r[U3FILTER <br /> ACH LINES ❑ LEACHING CHAMBERS #OF LINES , LENGTH OF LINES L�_0 T ft <br /> : r <br /> DISTANCE TO NEAREST• WELL 161 ft FOUNDATION a 1 ft PROPERTY LINE + ft <br /> BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ` <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> r❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 0 DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> �r <br /> SEEPAGE PITS WIDTH (Fv ft LSI ` ft DEPTH ��I ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> M[N MUM 4 HOUR ADVANCE NOTICE REQUIRED FOR INS/P�ECTION/S� PLEASE CALL(209)953-7697 <br /> SIGNED - TITLE Cr n T 7 G fO DATE <br /> i O <br /> i � <br /> > <br /> f <br /> FY1 <br /> I <br /> r <br /> r <br /> JCi <br /> 1 ,f NC <br />